ok. let me get you started.
first of all, you can't choose any nursing diagnoses until you have gone through your assessment data. so far, all i know about your patient is her medical diagnoses and just a couple of symptoms that you've listed:
- addicted to pain meds (substance abuse)
labwork suggesting anemia (is that what you meant?)
rbc count (what was it?)
low sodium (what was the actual reading?)\
i&o (big numbers?)
you can't start choosing any nursing diagnoses until you have symptoms that will support what is causing any nursing diagnosis. according to what you have posted, you have labwork and an rbc count which are symptoms that would support a nursing diagnosis of ineffective protection r/t abnormal blood profiles
. this will account for problems incurred due to the anemia. interventions would include monitoring further labwork and the evidence of any type of bleeding or risk for bleeding. fluid volume loss is also something that needs to be monitored for with this diagnosis. these patients shouldn't be getting any nsaids either, so if her pain medications are compound medications that contain any nsaids then the doctor needs to be contacted and the order clarified. this would be a collaborative nursing intervention.
pain. . .two days fetching prn meds for a patient makes me think this qualifies for a nursing diagnosis. is not using pain for a nursing diagnosis something your instructor mandated? if it were my care plan i would see two choices here. acute pain
or chronic pain r/t physical or psychological injury
. the use of either depends on the circumstances surrounding the pain. you haven't provided me with enough information from her assessment data to explain why she was receiving pain medication. no doctor is going to order pain medication without a reason. the doctor would have listed this in the h&p if she is a long-term user. if she is a long-term user, is she an abuser? was that stated? if so, that is a valid medical diagnosis. a medical diagnosis of drug abuse or addictive behavior nets a whole bunch of possible nursing diagnoses:
- anxiety r/t lack of control in use of drugs
- powerlessness r/t inability to change the pattern of abuse
- ineffective coping
- disturbed thought processes
- imbalanced nutrition: less than body requirements r/t poor eating habits [there may be relation between this and her anemia?]
constipation. . .is she on stool softeners or laxatives? narcotics are contributing factors to constipation. if so, even with the collaborative interventions of the stool softeners or laxatives there are still some independent nursing actions that can be taken such as providing a diet higher in fiber and encouraging fluids.
fluid volume deficit. . .if the patient is having huge fluid outputs of urine i don't think fluid volume deficit is a diagnosis to use because you don't necessarily have any symptoms to support it. normally, the patient would have weakness, weight loss, poor skin turgor, decreased urine output, thirst, elevated heart rate from their normal rate and decreased blood pressure. if you used this diagnosis your statement would have to read something like fluid volume deficit r/t inability to conserve fluid aeb urine output greater than fluid intake
. are you sure there is no renal problem going on here? was the patient being worked up for this? i was thinking more along the lines of impaired urinary elimination
. then, again, i'm sitting here asking myself why she might have a low sodium level.
normally i tell students to look at their list of assessment data. pull out all the abnormal data. that data, or symptoms, become the basis of support for any of the nursing diagnoses you will eventually use. and, your nursing interventions under each nursing diagnosis are always aimed at each one of these pieces of abnormal data that support the nursing diagnosis. i recommend that you go through your books and look up the signs and symptoms of anemia, constipation, bipolar disorder, and addicted behavior, the medical diagnoses you listed as belonging to this patient. see if any of them match up with the patient. if they do, then include them with your assessment data. chalk it up to a failure to notice them when you did her chart review and physical review of systems and assessment. plan on doing better with your next patient. some of those symptoms may help support the nursing diagnoses you want to use. until you get this list of symptoms, you are going to have problems going any further with this care plan. the symptoms help solidify and justify each nursing diagnosis. the nursing interventions just fall into place once that has occurred because each of the nursing interventions will address one of the supporting symptoms.
i hope you find that helpful. if you are still having problems with this, post again for more help. if you haven't already reviewed the information in the following threads, you should:
- http://allnurses.com/forums/f205/hea...ms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum)
- http://allnurses.com/forums/f205/des...ns-170689.html - desperately need help with careplans (in nursing student assistance forum)
- http://allnurses.com/forums/f50/care...-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum)